Cognitive-Behavioral Treatment of Insomnia

Insomnia is the most prevalent sleep disorder, representing one of the most common complaints reported to doctors by their patients. Treatment of insomnia usually involves prescription medications that have sedating properties. It has long been recognized, however, that this is a suboptimal approach for many patients for reasons including: residual daytime sedation, lack of data on the safety of long-term use, and the resistance of many patients to taking medications. In an effort to provide non-pharmacologic treatment options for insomnia, research and clinical practice have focused on developing cognitive-behavior treatments as an alternative.

Cognitive-behavioral treatment of insomnia, or CBT-I for short, represents a collection of techniques that are used to treat insomnia either in isolation or in combination with medications. The components of a typical CBT-I 'package' are: sleep hygiene, relaxation exercises, stimulus control, sleep restriction, and cognitive restructuring.

Once sufficient sleep drive
accumulates,
patients begin to
spend a higher proportion
of
their time in bed actually asleep.

Sleep hygiene refers to habits that patients engage in that can either promote healthy sleep or, if ignored, can interfere with sleep. For example, caffeine can counteract sleepiness but can also hamper the ability to fall asleep at night if used too late in the day. Patients can be educated about good sleep hygiene practices and then assisted in identifying ways they can change their sleep habits.

Insomnia usually is accompanied by physical and/or mental tension while trying to fall asleep. In order to counteract this tension, CBT-I includes instruction in relaxation techniques. There are a wide range of techniques available such as progressive muscle relaxation, autogenic training, and guided imagery. The choice of which strategy to use depends on the needs of each individual patient.

Individuals with chronic insomnia have spent so much time tossing and turning in bed that they develop a conditioned association between their bed and wakefulness and tension. The goal of stimulus control is to break this negative association and develop a healthy association between the bed and sleep. Patients are instructed to avoid sleep-incompatible activities in bed (such as watching TV) and to get out of bed if they are unable to fall asleep.

The rationale behind sleep restriction therapy
is to take advantage of sleep deprivation. Patients
with insomnia frequently spend excessive time
in bed in an attempt to get as much sleep as
possible. In sleep restriction, time spent in
bed is reduced, leading to increasing sleep deprivation.
Once sufficient sleep drive accumulates, patients
begin to spend a higher proportion of their time
in bed actually asleep. Once this happens they
are instructed to increase their time in bed.
As with many CBT-I techniques, sleep restriction
can help break the cycle of insomnia for patients.

Lastly, many patients with insomnia have an exaggerated degree of worry about the effects of a poor night of sleep and the consequences of insomnia. For example, they may lie in bed awake feeling that the next day will be ruined because they are having trouble sleeping. This fuels worry about the insomnia, further interfering with sleep. In reality, although they may be tired it is unlikely that the next day will be a complete loss. Cognitive restructuring is a technique for teaching patients to identify these inaccurate beliefs and challenge them in order to develop more realistic attitudes.

CBT-I has been shown to be an effective treatment for insomnia, rivaling or even surpassing the effectiveness of medications in randomized, controlled studies. One barrier to clinical implementation of CBT-I has been the lack of practitioners trained in these techniques.

Penn Sleep Centers recently opened its first clinic dedicated to CBT-I under the direction of Philip Gehrman, Ph.D. Dr. Gehrman is a clinical psychologist who specializes in CBT-I and also conducts research investigating the interactions of biological and psychological processes in the etiology of insomnia.